Client Questionnaire

    Your Name (required)

    Your Email (required)

    Select Today's Date(required)

    Height (required)

    Weight (required)

    Age (required)

    1. Has your doctor ever said that you have a heart condition and that you should
    only perform physical activity recommended by a doctor?
    yesno

    2. Do you feel pain in your chest when you perform physical activity?
    yesno

    3. In the past month, have you had chest pain when you were not performing any
    physical activity? (required)
    yesno

    4.Do you lose your balance because of dizziness or do you ever lose
    consciousness? (required)
    yesno

    5. Do you have a bone or joint problem that could be made worse by a change in
    your physical activity? (required)
    yesno

    6. Is your doctor currently prescribing any medication for your blood pressure or
    for a heart condition? (required)
    yesno

    7. Do you know of any other reason why you should not engage in physical
    activity? (required)
    yesno

    If you have answered “Yes” to one or more of the above questions, consult your physician before
    engaging in physical activity. Tell your physician which questions you answered “Yes” to. After a
    medical evaluation, seek advice from your physician on what type of activity is suitable for your
    current condition.


    GENERAL & MEDICAL QUESTIONNAIRE

    1. What is your current occupation? (required)

    2. Does your occupation require extended periods of sitting? (required)
    yesno

    3. Does your occupation require extended periods of repetitive movements? (If yes,
    please explain.) (required)
    yesno

    4. Does your occupation require you to wear shoes with a heel (dress shoes)? (required)
    yesno

    5. Does your occupation cause you anxiety (mental stress)? (required)
    yesno

    6. Do you partake in any recreational activities (golf, tennis, skiing, etc.)? (If yes, please
    explain.)
    yesno

    7. Do you have any hobbies (reading, gardening, working on cars, exploring the Internet,
    etc.)? (If yes, please explain.)
    yesno

    8. Have you ever had any pain or injuries (ankle, knee, hip, back, shoulder, etc.)?
    (If yes, please explain.)
    yesno

    9. Have you ever had any surgeries? (If yes, please explain.)
    yesno

    10. Has a medical doctor ever diagnosed you with a chronic disease, such as
    coronary heart disease, coronary artery disease, hypertension (high blood
    pressure), high cholesterol or diabetes? (If yes, please explain.)
    yesno

    11. Has a medical doctor ever diagnosed you with a chronic disease, such as
    coronary heart disease, coronary artery disease, hypertension (high blood
    pressure), high cholesterol or diabetes? (If yes, please explain.)
    yesno

    By Checking this box I Agree that all information provided is correct to my knowledge (required)